Development of a Tool to Stage Households’ Readiness to Change Dietary Behaviours in Kerala, India

RESEARCH ARTICLE Development of a Tool to Stage Households’ Readiness to Change Dietary Behaviours in Kerala, India Meena Daivadanam1,2,3*, T. K. Sundari Ravindran1, K. R. Thankappan1, P. S. Sarma1, Rolf Wahlström2,4 a11111 1 Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, 695011, India, 2 Dept. of Public Health Sciences (Global Health), Tomtebodavagen 18A, Karolinska Institutet, 171 77, Stockholm, Sweden, 3 Dept. of Food, Nutrition and Dietetics, Uppsala University, Box 560, SE-751 22, Uppsala, Sweden, 4 Family Medicine and Preventive Medicine, Dept. of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden * Abstract OPEN ACCESS Citation: Daivadanam M, Ravindran TKS, Thankappan KR, Sarma PS, Wahlström R (2016) Development of a Tool to Stage Households’ Readiness to Change Dietary Behaviours in Kerala, India. PLoS ONE 11(11): e0165599. doi:10.1371/ journal.pone.0165599 Editor: Gayle E. Woloschak, Northwestern University Feinberg School of Medicine, UNITED STATES Received: September 23, 2014 Accepted: October 16, 2016 Published: November 18, 2016 Copyright: © 2016 Daivadanam et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: Data will be made available to interested researchers upon request. The ethical clearance for this study does not include public data deposition; hence, such deposition cannot be done at this point. Moreover, under the rules of the Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, India, where the data collection was carried out, the doctoral advisory committee (DAC) is deemed to be the body responsible for doctoral research and all related Dietary interventions and existing health behaviour theories are centred on individuals; therefore, none of the available tools are applicable to households for changing dietary behaviour. The objective of this pilot study was to develop a practical tool that could be administered by community volunteers to stage households in rural Kerala based on readiness to change dietary behaviour. Such a staging tool, comprising a questionnaire and its algorithm, focusing five dietary components (fruits, vegetables, salt, sugar and oil) and households (rather than individuals), was finalised through three consecutive pilot validation sessions, conducted over a four-month period. Each revised version was tested with a total of 80 households (n = 30, 35 and 15 respectively in the three sessions). The tool and its comparator, Motivational Interviewing (MI), assessed the stage-of-change for a household pertaining to their: 1) fruit and vegetable consumption behaviour; 2) salt, sugar and oil consumption behaviour; 3) overall readiness to change. The level of agreement between the two was tested using Kappa statistics to assess concurrent validity. A value of 0.7 or above was considered as good agreement. The final version was found to have good face and content validity, and also a high level of agreement with MI (87%; weighted kappa statistic: 0.85). Internal consistency testing was performed using Cronbach’s Alpha, with a value between 0.80 and 0.90 considered to be good. The instrument had good correlation between the items in each section (Cronbach’s Alpha: 0.84 (fruit and vegetables), 0.85 (salt, sugar and oil) and 0.83 (Overall)). Pre-contemplation was the most difficult stage to identify; for which efficacy and perceived cooperation at the household level were important. To the best of our knowledge, this is the first staging tool for households. This tool represents a new concept in community-based dietary interventions. The tool can be easily administered by lay community workers and can therefore be used in large population-based studies. A more robust validation process with a larger sample is needed before it can be widely used. PLOS ONE | DOI:10.1371/journal.pone.0165599 November 18, 2016 1 / 13 Development of a Dietary Staging Tool for Households matters and the guide (main supervisor) is the chair. The data will therefore be made available to interested researchers upon request to the first author () or the chair of the DAC (, ) that oversaw the doctoral studies of the first author. Funding: The authors acknowledge funding for doctoral studies received by the first author (MD) from Erasmus Mundus Scholarship (external cooperation window, lot 13). Competing Interests: The authors have declared that no competing interests exist. Introduction Dietary behaviour is the result of a complex interplay between food-related factors and other individual and environmental factors [1–3], which exert varying degrees of influence, depending on the context [4]. Similarly, dietary behaviour change involves more than choosing healthy foodstuffs; it includes making the decision to change and the actual process of change itself [1, 2, 5]. Health behaviour theories like the trans-theoretical model (TTM) and the social cognitive theory have been used as theoretical frameworks to understand food choice issues; predict dietary behaviour; develop interventions to change food habits; and facilitate the behaviour change process [5–7]. The TTM is the most widely used change model that describes the process of change, its initiation and maintenance [2, 8, 9]. It has been most commonly used to stage individuals for predicting potential for behaviour change or delivering stage-matched interventions [7]. The evidence regarding effectiveness of stage-matched interventions is mixed [9, 10]. However, it provides a method of identifying individuals at similar levels of willingness and motivation to change, which allows for more focussed intervention approaches. Health behaviour theories, including TTM, are centred on the individual making the choice [11]. Consequently, existing staging tools or algorithms based on TTM are also focussed on individuals [5], and cannot be directly applied to households (HHs) as a whole. It therefore becomes a challenge regarding food choices and behaviour change, as decision-making is partly influenced by all individuals in the family by virtue of various power relations, and also by society [12]. In the context of rural Kerala in India, we have already found that dietary decisions are taken at the household level and that costs were the primary consideration, money costs in particular [13, 14]. The hierarchy of household members in terms of food preferences and the value ascribed to various foodstuffs were more important than their perceived health value [13]. Irrespective of their employment status, women’s identities, also strongly embedded as housewives and mothers had the primary responsibility to keep “husbands and children well fed (...truncated)